What to Do If an Insurance Company Will Not Pay a Claim?

When you purchase an insurance policy, you expect that the coverage the insurer promises to provide will be there in your time of need. However, because insurance companies earn profits in large part by attempting to minimize claim payouts, they aren't always eager to cooperate. If your insurance company initially denies your claim, you don't have to take "no" for an answer.

Determine the Reason

When your insurance company denies a claim, you should receive a written explanation for its action. A common reason for the denial is the company's belief that your policy does not provide coverage for your particular situation. Read your policy carefully, especially the section that pertains to denial of coverage, to determine if you agree with the company's decision. You can also contact your insurance agent for additional clarification. Keep in mind, however, that agents typically do not have the authority to change the decision.

Contact Claims Department

Your initial investigation may lead you to believe your insurer denied your claim erroneously. If so, your next step is to contact the company's claims department for further explanation. Your denial letter as well as your insurance card or other coverage documentation should contain contact information. Prepare a list of all your questions in advance, and remain calm during your discussion. In some cases, a simple clerical error or other correctable mistake could have led to the denial. If you are not satisfied with the responses you receive, ask to speak to a supervisor.

Formal Appeal

If you're still not making progress, consider filing a formal appeal. Your policy or the denial letter should contain information about how to start the appeal process. You likely will need to make the appeal in writing, and be prepared to include any documentation that supports your case. Appeals generally must be filed within a certain period of time after a denial, so get started on the process as soon as possible.

State Insurance Department

Your insurer could decide to deny your appeal. If so, consider contacting your state's department of insurance for assistance. Most insurance departments have a process in place for resolving consumer complaints. As when filing a formal appeal, time restrictions for filing a complaint typically apply. If this proves unsuccessful or your state does not offer this service, you may need to resort to professional arbitration or even taking legal action to resolve the matter.